Disclaimer: The views and opinions expressed in this article are those of authors and do not necessarily reflect the official policy or position of UNFPA and ICOMP. The content in this draft article should not be quoted.

The Status of Family Planning and Reproductive Health in Indonesia

Adrian C. Hayes

UNFPA - ICOMP REGIONAL CONSULTATION

Family Planning in Asia and the Pacific

Addressing the Challenges

8-10 December 2010, Bangkok, Thailand

Draft for Consultation – Not to be quoted

1

Draft 10 Nov 2010

Preliminary Draft Report for Comment

Before High-level Family Planning Consultation Meeting,

Bangkok, 8-10 December 2010

THE STATUS OF FAMILY PLANNING AND REPRODUCTIVE

HEALTH IN INDONESIA, 2010

Adrian C. Hayes

Australian National University

1 Aims of the Report

The International Conference on Population and Development (ICPD) in 1994 adopted a

Programme of Action with an ambitious goal:

All countries should take steps to meet family-planning needs of their

populations as soon as possible and should, in all cases by the year 2015, seek

to provide universal access to a full range of safe and reliable family-planning

methods and to related reproductive health services which are not against the

law (UN 1994: para 7.16; emphasis added).

Today there is widespread a view that neither the international community nor the majority of

national governments have pursued the Cairo Programme with the level of commitment it

requires and deserves. Many national family planning programmes appear to have lost focus

and momentum.

Against this background the International Council on Management of Population

Programmes (ICOMP) and the Asia and Pacific Regional Office of the United Nations

Population Fund (UNFPA) are undertaking a review of the status of family planning in

selected countries of Asia and the Pacific. The present country report is one component of

this broader undertaking.

The aims of this report are to:

provide a succinct review of the overall status of family planning (FP) and related

reproductive health programmes in Indonesia today;

identify key issues and obstacles which may be limiting universal access to quality FP

services; and

make recommendations (where appropriate) regarding how the provision of services

and practice of FP can be improved by “repositioning,” “revitalizing,” or otherwise

adjusting the national FP programme.

2

2 Past Achievements in FP/RH

President Suharto introduced a national family planning program in 1968 and established the

National Family Planning Program – well known around the world by its Indonesian

acronym, BKKBN – in 1970. BKKBN was charged with developing a national FP program

and with managing foreign aid provided for this purpose. The program was a great success

and fertility levels dropped dramatically (Figure 1). According to the latest UN estimates the

total fertility rate (TFR) declined from 5.6 live births per woman per lifetime in 1965-70 to

3.4 in 1985-90 (UN 2009). President Suharto was presented the UN Population Award in

1989 in recognition of this success. The Indonesian FP program was “widely recognized as

one of the most successful in the world” (Piet 2003: 83). The latest UN estimate for TFR

today (2005-10) is 2.2 (see also Hartanto and Hull 2009).

Figure 1. TFR, Indonesia, 1950-2010

Source: UN (2009).

If the current status of FP is to be assessed accurately it is important to understand the factors

underlying this early success. Those working in the FP program committed to solving the

country‟s “population problem” often spoke (and wrote) at the time as if success derived

exclusively from “program effort.” It is true the program enjoyed inspired leadership during

most of its first quarter century and that BKKBN was able to recruit many of the best new

entrants into the civil service to produce an impressive and effective “can-do” organization

(Hull 2007). On top of this the program had the strong enthusiastic support of President

Suharto which guaranteed generous resources (including foreign assistance) and political

leverage.

But there were other important non-program factors at work too. Suharto‟s authoritarian New

Order government established a highly centralized state apparatus which reached down into

villages and tolerated no organized opposition; without this broader political-administrative

system in place it is difficult to believe BKKBN could have expanded and coordinated the FP

0

1

2

3

4

5

6

1950-55 1960-65 1970-75 1980-85 1990-95 2000-05

TFR

3

program so effectively (Hull and Hull 1997).1 The New Order government maintained

political stability and impressive economic growth during most of 1970-95 and these factors

too contributed to many people wanting smaller families. The dramatic decline in fertility

was in fact due to a combination of many factors, although no one denies the program

contributed significantly to the timing and quick pace of the fertility decline and that the rapid

expansion in FP services led to improved health and well-being for millions of Indonesians. It

is important to acknowledge the role of non-program factors in the early success of the

program because when we examine the change in status of the FP program in Indonesia today

we find it is has a lot to do with changes in non-program contextual factors.

Figure 2. CPR, Indonesia, 1987-2007

Source: IDHS.

By the early 1990s the FP program was at its zenith. The Indonesia Demographic and Health

Survey (IDHS) showed that the contraceptive prevalence rate (CPR) for currently married

women aged 15-49 had reached 50 percent.2 (There were no national surveys to measure

CPR in the 1960s but it is estimated the rate was significantly below 10 percent in 1970.)

However by the end of the decade it was obvious to many observers the program was

beginning to lose steam. The apparent “plateauing” of the CPR at around 60 percent was

often taken as a clear signal of this (Figure 2). The steady increase in CPR for modern

1 According to the Hulls (1997: 392, 384), “the most dramatic achievement of the New Order government of the

period 1966-90 was the major construction of state and civil institutional structures in ways that enhanced

central government control while promoting decentralized responsibilities.” It was, they argue, the government‟s

unique way of using the instruments of social control made available by this political-administrative system

which, in combination with a highly patrimonial state ideology committed to political stability, was responsible

for the success of “a wide variety of popular government programmes including primary schooling, health

service delivery, and family planning.” For further elaboration of this point see also Hull (2003) and Piet (2003). 2 DHS data were collected in Indonesia in 1987, 1991, 1994, 1997, 2002/03, and 2007. The 1987 DHS was

actually a National Contraceptive Prevalence Survey; it covered 20 of the country‟s 27 provinces at the time,

and so was representative of 93.7 percent of the national population. The surveys in 1991, 1994, and 1997 were

“complete” DHS and are representative of the national population as a whole. The DHS in 2002/03 covered 26

of the 33 provinces in Indonesia at that time: Nangroe Aceh Darussalam, Maluku, North Maluku, and Papua

were not included for security reasons (and East Timor was dropped because no longer part of Indonesia). The

last IDHS, conducted in 2007, covered the whole country.

0

10

20

30

40

50

60

70

1986 1989 1992 1995 1998 2001 2004 2007

all methods modern methods Poly. (all methods)

4

methods during the 1990s was at a slower pace at the end of the decade than at the beginning

of the decade, and during the most recent period 2002 to 2007 it was increasing at an average

of only one fifth of one percentage point per year (Table 1). In fact the challenges facing the

FP program since the mid-1990s are much more complex than any single indicator can

suggest, as we discuss in the following two sections.

3 Current Issues in the National Program

There is a long litany of unresolved issues and challenges facing the Indonesian FP planning

program today. For convenience we discuss them under four major headings: changing

demographics, political decentralization, the changing international agenda, and the growing

demand for “good governance” (Figure 3).

3a Changing demographics

As a country goes through its demographic transition the demographic profile of its

population changes. This in turn results in changes in the demand for FP and RH services,

and successful programs need to be responsive to this.

Demand for services

We have already noted the apparent recent plateauing of CPR. This does not pose a major

problem for future population growth since the balance of evidence suggests the TFR is

already quite close to replacement level. A more urgent concern is that such plateauing

around 60 percent is associated with continuing unmet need. Unmet need for FP is defined by

the DHS as “the percentage of currently married women who either do not want any more

5

children or who want to wait before their next birth, but who are not using any method of

family planning” (BPS & ORC Macro 2003: 85).3

Table 1. CPR (currently married women 15-49), Indonesia, 1987-2007

1987 1991 1994 1997 2002/03 2007

CPR all methods 47.7 49.7 54.7 57.4 60.3 61.4

CPR modern methods 44.0 47.0 52.0 54.7 56.7 57.4

Average annual

increase in CPR for

modern methods since

previous survey

(percentage points per

year)

-- 0.8 1.5 0.9 0.4 0.2

Source: IDHS.

Unmet need for FP (expressed as percent of CMW 15-49) continued to decline during the

1990s even as total demand continued to rise, but remains around 9 percent during 1997-2007

(Table 2). In absolute terms the number of CMW 15-49 with unmet need continued to

increase. In short, a plateauing of CPR around 60 percent is not consistent with the

Government‟s stated policy objective of ensuring FP services are available to all married

couples who need them.4

Table 2. Need and total demand for FP (currently married women 15-49), 1987-2007

1987 1991 1994 1997 2002/03 2007

Met need for FP:

For spacing

For limiting

Total

47.7

18.7

31.0

49.7

22.6

32.2

54.7

25.2

32.1

57.4

24.2

36.2

60.3

25.1

36.3

61.4

Unmet need for FP:

For spacing

For limiting

Total

19.8

21.4

41.2

6.3

6.4

12.7

4.8

5.8

10.6

4.2

5.0

9.2

4.0

4.6

8.6

4.3

4.7

9.1

Total demand for FP:

For spacing

For limiting

Total

25.4

37.9

63.3

28.1

38.3

66.3

30.0

37.4

67.4

28.8

41.0

69.7

29.5

41.1

70.6

Percentage of demand

satisfied

79.9

84.0

86.4

87.6

87.2

Source: IDHS.

3 The definition is specified further as follows: “Women with an unmet need for „spacing‟ include pregnant

women whose pregnancy was mistimed; amenorrheic women whose last birth was mistimed; and fecund

women who are neither pregnant nor amenorrheic, who are not using any method of family planning, and who

want to wait two or more years for their next birth. Also included in unmet need for spacing are fecund women

whoa re not using any method of family planning and are unsure whether they want another child or who want

another child but are unsure when to have the birth. Unmet need for „limiting‟ refers to pregnant women whose

pregnancy was unwanted; amenorrheic women whose last child was unwanted; and women who are neither

pregnant nor amenorrheic, who are not using any method of family planning, and who want no more children.”

Ross (2003) argues the DHS definition is too conservative and that a more realistic definition means unmet need

is actually a few percentage points higher. 4 For a more general account of plateauing, including some speculation on possible causes, see Ross, Abel and

Abel (2004).

6

Method choice

Even if changes in CPR are currently slow this does not mean that FP is static. There are

striking trends in method mix, especially increasing reliance on injectables and a shift away

from the IUD (Table 3). By 2007 45.0 percent of all currently married women are using

short-term hormonal methods, or more than two-thirds of those practicing FP. Sterilization

meanwhile remains below 5 percent.

These trends in method mix warrant attention. Although the medical evidence

overwhelmingly suggests that low-dose modern hormonal methods pose no serious health

risk (except for those with counter-indications), some health practitioners still caution

whether it is wise for a woman to take hormones for decades, especially when other non-

hormonal long-term methods are available.5 Second, some FP program experts (e.g. Ross

2003) argue it may be additionally difficult to reach the high levels of CPR needed to attain

long-term population stabilization if a program relies heavily on short-term “re-supply

methods” because of the “churning effect” among the program‟s clients. A program that

depends heavily on short-term methods requiring constant re-supply is especially vulnerable

to disruption during turbulent times (e.g. during a transition to decentralization). A program

with more clients on long-term methods can focus more attention on reaching those couples

still with unmet need.

Table 3. Trends in use of contraceptive methods among CMW, 1987-2007

Method 1987 1991 1994 1997 2002/03 2007

Pill 16.1 14.8 17.1 15.4 13.2 13.2

IUD 13.2 13.3 10.3 8.1 6.2 4.9

Injection 9.4 11.7 15.2 21.1 27.8 31.8

Condom 1.6 0.8 0.9 0.7 0.9 1.3

Implants 0.4 3.1 4.9 6.0 4.3 2.8

Female sterilization 3.1 2.7 3.1 3.0 3.7 3.0

Male sterilization 0.2 0.6 0.7 0.4 0.4 0.2

Periodic abstinence 1.2 1.1 1.1 1.1 1.6 1.5

Withdrawal 1.3 0.7 0.8 0.8 1.5 2.1

Other 1.2 0.9 0.8 0.8 0.5 0.4

Any method 47.7 49.7 54.7 57.4 60.3 61.4 Source: IDHS.

Adolescents and the unmarried

Other significant trends the FP program must respond to concern changing patterns in family

formation. At the time of the 2000 Population Census almost one third of all women 15-49

(32.9 percent, or 18.5 million women) were not currently married. Table 4 shows the sharp

rise in percent never married for the under-30 female age groups. For both sexes 92 percent

of all young people 15-19 are single (in 2000), and 58 percent of those 20-24. Eighty-four

percent of all young people 10-24 have never been married.

5 From an evolutionary perspective on population health, see the comments on oral contraception, menstruation,

and increases in cycles of cellular proliferation by McMichael (2001: 216-219).

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Table 4. Marital status of women (15-49) by age, 1990, 2000

15-19 20-24 25-29 30-39 40-49 15-49

1990 2000 1990 2000 1990 2000 1990 2000 1990 2000 1990 2000

Never

married

81.8 86.7 35.7 43.1 11.2 16.7 3.7 5.3 1.8 2.2 26.6 28.5

Married 17.0 12.7 60.8 55.0 84.1 80.5 89.4 89.8 82.5 86.7 67.2 67.1

Divorced 1.1 0.5 3.1 1.6 3.7 2.2 4.0 2.9 4.7 3.5 3.3 2.2

Widowed 0.1 0 0.4 0.3 0.9 0.6 2.9 2.0 11.1 7.6 2.9 2.2

Total 100.0 99.9 100.0 100.0 99.9 100.0 100.0 100.0 100.1 100.0 100.0 100.0 Source: BPS 1992, 2002.

According to the 2002-2003 IDHS, among women currently 25-29 years old the median age

at first marriage is 20.2 years, compared to 17.9 years reported by women currently 45-49.

Among women currently 20-24 only four out of ten were married by age 20, while for those

currently 45-49 seven out of ten were married by age 20. Urban women marry later than

rural, and those with more education marry later than those with less. The median age at first

marriage among women currently 25-29 who have some education above the secondary level

is 23.9 years.

The long interval common nowadays between puberty and marriage represents an intensely

challenging period in the development of a young person‟s life, and the way she or he deals

with it helps determine her or his future life-chances and adult personality. Young people

need information and other services to help them navigate this stretch of their life, and most

importantly they need information and services to help protect their reproductive health. The

changing demographics of Indonesia as it completes its demographic transition are placing

growing pressure on FP program managers to provide additional services for the growing

proportion of population that is currently unmarried. A FP program that continues to restrict

itself to providing services almost exclusively to married couples will necessarily miss a vital,

and increasingly large, part of the action.

Source of supply

Another major trend is that FP clients have been shifting to the private sector at a rapid rate in

recent years (Table 5). The 2007 IDHS reports 69.1 percent of clients using a “private

medical” source of supply, or more than 75.0 percent when “other private” sources are

included. Government-provided “public” sources account for only 22.2 percent. The trend

towards the private sector was, if anything, accelerated by the Asian Financial Crisis at the

end of the 1990s (Strauss et al. 2004). The precise details are complicated because the public-

private distinction is not clear-cut, with many private practitioners also working in the public

sector, and because what gets listed under each category heading of “source” in the IDHS has

changed over the years (e.g. posyandu is listed as a “Government source” in 1991, as “Other

private” in 1994 and 1997, and as “Other source” in 2002/03: see Table 5). Nonetheless, the

overall trend in privatization is clear, and is corroborated by other data sources such as annual

National Socio-Economic Survey (SUSENAS) and the Indonesia Family Life Survey (IFLS).

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Table 5. Source of supply for modern contraceptive methods, 1991-2007

Source 1991 1994 1997 2002/03 2007

Public 51.2 48.6 43.0 28.0 22.2

Medical private 22.1 28.1 41.9 62.5 69.1

Other privatea 26.7 23.1 15.1 9.4

8.6

Missing 0.0 0.0 0.1 0.1 0.1

Total 100.0 100.0 100.0 100.0 100.0 Source: IDHS. aThis includes “community sources,” namely, posyandu and family planning post.

This trend in privatization is broadly consistent with the Government‟s objectives; the policy

of KB Mandiri (“self-reliant family planning”) was first introduced in 1989. Policymakers

still needs to question some of the nuances of this trend, however. One obvious question is

whether as the program becomes increasingly privatized this leads to a rise in clients‟ out-of-

pocket costs so as to cause any among the poor to lose access to services. Another question is

whether the private sector is adequately regulated to guarantee a satisfactory minimum

standard of services, and whether adequate systems of redress are in place when needed.

There is also a question regarding whether providers in the private sector are equipped and

motivated to provide adequate choice of methods to clients, or whether the method mix to

some extent may reflect a provider bias (e.g. the heavy reliance on injectables provided by

private midwives).

Finally, there are sensitive questions about just how self-reliant the private sector really is,

and how much it relies on indirect or hidden government subsidies, for example the well-

known “leakage” of subsidized FP commodities from the public sector into the private, and

the fact that private providers still get trained (and retrained) at public expense and often use

publicly-provided facilities and equipment (Lubis 2003: 46-48). Most of these “exchanges”

across the public-private divide may be legitimate but some can be shown to undermine the

Government‟s stated commitment to privatization.

Regional and socioeconomic differences

Another area of concern for program managers is that considerable regional differences in the

practice of FP still exist in Indonesia (Table 6). Some provinces have CPR for modern

methods higher than 60 percent (Jambi 62.5, South Sumatera 62.6, Bengkulu 70.4, Lampung

66.0, Bangka-Belitung 64.7, West Java 60.3, Central Java 60.0, East Java 62.3, Bali 65.4,

West Kamilantan 61.2, Central Kalimantan 65.2, South Kalimantan 63.2, and North Sulawesi

66.7); others are under 45 percent, notably North Sumatera 42.6, East Nusa Tenggara 30.1,

South Sulawesi 42.9, Southeast Sulawesi 44.4, West Sulawesi 44.5, Maluku 29.4, Papua

24.5, and West Papua 39.6). It is important to focus on unmet demand in the last 8 provinces

if universal access to FP services by 2015 is to be achieved.

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Table 6. CPR (modern methods) for selected provinces, 1987-2007

Province 1987 1991 1994 1997 2002/03 2007

N.Sumatra -- 34.0 40.2 42.0 43.2 42.6

Bengkulu -- 55.9 60.2 62.3 64.0 70.4

W.Java 46 49.7 56.0 56.5 57.5 60.3

C.Java 54 48.1 59.6 61.4 62.2 60.0

E.Java 50 53.0 53.5 58.0 63.2 62.3

NTB -- 38.2 47.9 54.3 52.5 52.2

NTT -- 35.0 32.6 35.2 27.5 30.1 Source: IDHS.

The 2002/03 IDHS also includes a household wealth index.6 While CPR for modern methods

for all currently-married women 15-49 is 56.7 percent, it is only 43.4 percent for the

extremely poor women (lowest quintile) and 53.2 percent for the moderately poor (second

lowest decile) (Schoemaker 2004: 8). Schoemaker shows this is predominantly not because

the poor have more unmet need but because they want more children than the non-poor.

Schoemaker‟s analysis also highlights questions program managers need to address about the

targeting of subsidized FP services and supplies: Even among the extremely poor more

women rely on the private than the public sector for source of supply, while among the non-

poor just over 25 percent use the public sector (Schoemaker 2004: 17). The IDHS wealth

index cannot be taken as a definitive definition of poverty, but Schoemaker‟s analysis is

consistent with others (like Ross 2003, and Strauss et al. 2004) which suggest that the

government‟s subsidized FP services are not largely benefiting the poor in the way intended.

Finishing the job

These, then, are some of the challenges facing the FP program in Indonesia today resulting

from changing demographics as the country goes through the advanced stages of its

demographic transition. The consensus among friends and observers of the program is that it

is not tackling these challenges especially well, and that BKKBN is certainly not formulating

innovative solutions and coordinating their implementation with the focus and determination

the organization displayed during the 1970s and 80s. The question is, Why?

The overall goals of the program – giving couples the information and means they need to

control their own fertility, reducing high fertility to bring population growth more in line with

the nation‟s development goals, supporting the norm of the small prosperous family – have

remained remarkably stable since the program was launched in 1970. Policymakers have had

to adjust the intermediate objectives periodically, however, in response to changing

circumstances. Indeed as the program expanded rapidly during the 1970s and 80s new

approaches were constantly being tested and applied to increase coverage and institutionalize

FP as a social norm. By the 1990s a majority of couples were already practicing FP, and the

depth of their commitment was demonstrated by their resolve to continue even when some

supplies were disrupted for a while during the height of the Asian Financial Crisis. The

program seemed on track to deliver universal access to services by 2015 and to bring about

6 It is not used in the chapter on use of family planning in the published report, however.

10

the program‟s original goal of long-term population stabilization. Paradoxically it was at this

juncture that the program first appeared to lose its focus and stall.

We argue in the next section this was largely because of changes in the international and

institutional context in which BKKBN operates. BKKBN has not been able to take a

convincing leadership role in tackling the challenges listed above – what many would argue

should be regarded as its “core business” – because other changes in its institutional context

have effectively neutralized many of the non-program factors which were vital to its

organizational success in the past. BKKBN has not been able to focus during the last 15 years

on how its “core business” has evolved separately from tackling other formidable challenges

which have arisen regarding the international agenda, political decentralization, and

governance reform.

In the longer term the central government‟s responsibility will likely change in other ways

too. Government-sponsored national FP programs have finite life-spans. “Family planning

programs, like the fertility transition that they have helped to drive, will be a transient

phenomenon” (Caldwell et al. 2002: 1). More than a dozen countries in Asia have by now a

TFR at or below replacement level, and have, or are considering, disbanding their FP

programs. It is only a matter of time before the Government of Indonesia will want to phase

out much of its program support for FP services, except perhaps for the poor and other

vulnerable groups, and for areas where there is still a demonstrable need (cf. Jones and Leete

2002).

That does not mean the Government then has no further role to play regarding the delivery of

services. The Government will still need to develop national FP policy and guidelines, protect

people‟s reproductive rights, monitor districts‟ performance of essential FP/RH services, and

ensure satisfactory quality standards are followed by service providers in all parts of the

country, etc. The Government will also still need to monitor fertility behavior, and perhaps do

what it can to make sure that fertility in Indonesia does not eventually fall too far below

replacement, as it has in some neighboring countries (and most of Europe). But the publicly-

funded FP program as we know it will eventually likely be phased out or significantly

refocused and reduced in scale. In fact as we saw in Table 6, this process is already far along,

with only a minority of clients depending on the government for their routine FP services.

Senior BKKBN officials are, of course, aware of this situation whereby “success” can imply

redundancy for the organization, and are carefully weighing alternative scenarios. We give

our own recommendation on this point in section 5.

4 Understanding the Current Situation

4a Changing International Agenda

One set of challenges for the FP program arises because of vicissitudes in the international

agenda. The Programme of Action adopted at ICPD in 1994 is recognized as marking a

definitive shift in family planning ideology away from an approach oriented towards

population control and demographic targets and towards a client-oriented RH approach

11

emphasizing quality services and grounded in human rights.7 Sinding (2007: 10) has

characterized the situation as follows:

Cairo was truly a watershed. Some have already seen it as the end of the

family planning movement, an event celebrated by many feminists and

women‟s rights activists as a paradigm shift and equally regretted by

traditional population advocates, including many demographers and others

concerned about high fertility rates, as abandonment of a decades-long

commitment to population stabilization. In the years since the conference,

global attention has increasingly shifted away from population growth as a

central political or development concern, while the rising toll of HIV infection

and AIDS deaths has captured the attention of policy makers.

The Indonesian delegation was very active in ICPD.8 Cairo did not spell the end of the

national FP program in Indonesia but it did pose a hard dilemma for BKKBN. BKKBN was

set up as a stand-alone agency within the central government in order to take the lead on

population control. If FP was now to be seen as essentially a health and gender issue that

would imply handing over responsibility for FP policy to the MOH; after all, it was always

government health personnel and public health facilities which were actually delivering the

public FP services. This BKKBN was clearly reluctant to do. Without a radically new

mission it means BKKBN is stuck institutionally in an impossible position: they cannot move

forward and wholeheartedly embrace ICPD because that requires acknowledging that FP is

first and foremost a matter of RH and therefore belongs logically to the mission of the MOH,

and they cannot move backwards towards the direction of population control because that

requires using language no one else wants to speak anymore and the original “population

problem” has mostly be resolved by now anyway. Institutionally BKKBN are stuck between

the proverbial rock and a hard place.9

In short BKKBN chose not to redefine its central vision and mission explicitly in terms of

Cairo (i.e., in terms of promoting reproductive rights and reproductive health) even though it

has adopted specific elements from ICPD. As a result neither the goals of the government‟s

FP program nor the explicit contributions of BKKBN to the nation‟s development objectives

are defined today with the same clarity and conviction that they were during the 1970s and

80s. An increasing number of reproductive health advocates and feminists have come to

regard BKKBN as now “behind the curve” in matters of RH and FP (see, for example,

Juliantoro 2000).

7 In fact the Programme is more complex than this because it seeks to combine a number of perspectives on

population and development – the economic, ecological, NGO, etc. – and not just that of human rights (Hayes

1995). 8 On the pivotal issue of targets, BKKBN was already moving away from targets before Cairo and towards

“demand fulfillment” (see Galway 1996). 9 Similar agencies in other countries that were initially established with foreign assistance to manage vertical

population control programs presumably face a similar dilemma. ICPD articulated well an important paradigm

shift and the international community promptly shifted its support from one paradigm to the other, but it hasn‟t

offered much help when it comes to the practicalities of effecting such a change in the typical political context

of a developing country.

12

MDGs and numerical targets

At the same time the victory of women‟s RH advocates at the Cairo conference did not

translate into all the promised results either, and international funding for implementing the

Programme of Action has fallen far short of expectations (Schindlmayr 1999; Population

Action International 2005). When 189 member states adopted the Millennium Declaration in

September 2000 with the commitment to “making the right to development a reality for

everyone” and “creat[ing] an environment – at the national and global levels alike – which is

conducive to development and the elimination of poverty” (UN 2000), they did not include

RH as an MD goal or target, even though the Declaration was promoted as an explicit

culmination of the sequence of UN conferences held during the 1990s, including ICPD. The

omission was deliberate and calculated (Bernstein 2005; Crossette 2005).

UNFPA, the UN Millennium Project and other stakeholders continued to argue the case that

population and RH policy are essential elements of successful strategies to eradicate income

poverty and attain other MDGs. At the UN MDG+5 World Summit (in September 2005) the

ICPD goal of universal access to RH by 2015 was re-affirmed, and it was agreed this goal

should be integrated “in strategies to attain the internationally agreed development goals,

including those contained in the Millennium Declaration, aimed at reducing maternal

mortality, improving maternal health, reducing child mortality, promoting gender equality,

combating HIV/AIDS and eradicating poverty” (UN 2005: para 57g). There is an irony in

seeing FP and RH once again tied to development goals expressed as numerical targets. The

danger is that program managers will be rewarded more for meeting the numerical targets

than for bringing about the substantive changes that the numbers are meant to indicate.10

A review of current understanding of the linkages among population, RH and poverty

confirms that these factors are causally interrelated in significant ways, and that population

and RH can and do impact on poverty status, even though our understanding of all the

specific mechanisms involved is still far from complete (Hayes 2005). Practical measures,

therefore, to eradicate poverty need to take population matters into account, and improving

RH is important if they are to be effective. But whether the target-driven approach of the

MDGs is the best way to accomplish this is another question (Reddy and Heaty 2008).

The challenge for central and provincial level FP policymakers is to negotiate performance

targets for districts which fairly measure substantive improvements in FP/RH services, and

10 For example, a recent World Bank project aimed at helping the Indonesian Government bring about effective

decentralization of the health sector included a component aimed at personnel reform. One element was to

reduce the number of non-health staff at puskesmas (health centers – one of the main sites for publicly-

supported FP services). This was meant to be just one element in a broader package of HR reforms (getting rid

of unproductive staff, clear job descriptions, competency-based promotions, downsizing through early

retirement, etc.). However this element was given a numerical target (reduce by 20 percent by a certain date)

and the others were not. Consequently some district-level project managers chose to focus on reducing this

particular element so they could claim evidence of success in the component as a whole. The method often

chosen to accomplish this – using project funds to train non-health staff so they could then be classified as

health staff – was probably not cost-effective and certainly defeated the component‟s broader objective of a

smaller more efficient workforce (Hayes et al. 2007).

13

which do not serve to distort the incentive structure of FP and RH workers so as to reward

reaching easily-measurable yet essentially superficial changes rather than reaching more

substantial goals.

4b Decentralization

Effective 1 January 2004, most of BKKBN‟s authority for administering the program was

transferred to more than 420 “autonomous” districts (kabupaten) and municipalities (kota),

and much of its responsibility for developing FP policy is now shared with the regional

governments.11

When it became clear in early 2002 that BKKBN would be obliged to

decentralize the agency made a concerted effort to ensure that this transfer of authority would

go smoothly and that access to FP services would not suffer unduly. BKKBN advocated with

local government authorities to ensure that a suitable institutional home would be provided

for the FP program in the respective districts/municipalities after decentralization. It

developed, in consultation with regional governments and the Ministry of Home Affairs, a

list of “essential” family planning services which districts would be obligated by law to

provide, together with associated performance indicators to be used for monitoring. BKKBN

also managed to secure central government funds to enable it to continue providing

subsidized contraceptives (and some other supports) to districts on request.

BKKBN further negotiated a favorable institutional arrangement with the Government

whereby the BKKBN province offices could stay “vertical” under the direct control of

BKKBN at the central level (at least in the short term) rather than be part of the

administrative apparatus controlled by the provincial governor.12

Other proactive initiatives

included developing an Early Warning and Rapid Response System, so that even if (as

seemed inevitable) routine monitoring systems faltered in the early stages of decentralization,

BKKBN and other stakeholders could still have some basic information on how the program

was performing from a national perspective, and could identify emerging problems quickly

and work in partnership with districts to overcome them. BKKBN prepared for

decentralization with arguably more care and deliberation than any other government agency

involved with the delivery of public services.

Following decentralization FP program officials at all government levels now face new

challenges regarding sourcing resources, planning program activities, recruitment and

managing personnel, the scope of their authority for policy formulation, the need for

advocacy, their relations with other government and non-government units, reporting on

performance, financial reporting, and how their own performance will be evaluated. It is

important to recognize that decentralization in Indonesia involves both administrative and

political dimensions, so FP program officials cannot resolve all the administrative issues

involved before politicians resolve outstanding issues regarding the distribution of authority

across the central, province and districts levels of government.

11

For a review see USAID (2006). Decentralization has a long and complex history in Indonesia going back to

colonial times. 12

This kind of institutional arrangement is now largely pro forma after the 2004 decentralization laws.

14

Much of the technical assistance offered to BKKBN (and the Ministry of Health) has tended

to focus on technical issues as if the political issues have already been resolved. Sometimes

the “form follows function” adage is included with the advice offered. This assumes the

functions are already well defined, and often they are not. Even if they were, institutions in

the real world never adapt to functional requirements alone – every institution has its own

traditions, and those with power are able to influence processes of change in ways more

favorable to themselves; institutional reform is always path-dependent. Sometimes TA has

been offered to help define the functions; but as should be clear by now, this is partly a

political process, not a simple technical matter. In other words, problems facing the FP

program brought about by decentralization that often seem to outsiders to lend themselves to

technical solutions in fact often have an irreducible political component and therefore need to

be approached as governance issues.

4c The growing demand for good governance

Although there is little agreement on an exact definition of “good governance” as promoted

by international agencies and donors (see for example Jenkins and Plowden 2006), there is

broad agreement that items like freedom of speech, political party organization, public

accountability of governments, transparency in political decision-making, and an independent

judiciary, are all key components of a “healthy” democracy. Institutionalizing these items

systemically can also make sectors, including health and FP, more responsive to local

communities‟ needs and aspirations.

At the program level introducing elements like accountability and transparency are relatively

easy, and they engender local participation in, and ownership of, the program. Good

governance in this sense is an important part of the ICPD Programme of Action. An initial

obstacle, usually short-lived, is that in the early stages few officials or members of the public

are familiar with these notions and the mechanisms introduced tend to be weak and

innocuous: “accountability” is simply a “suggestions box” placed at a service delivery point,

for example. Good governance depends crucially on the development of strong civil society

institutions, not just on an efficient state apparatus, and program managers might not see it as

their responsibility to foster this. Indonesian NGOs are increasingly effective in promoting

good governance. Good governance and strong civil society institutions are needed to check

that key “principals” in the state apparatus at all levels do indeed serve the public interest and

that services are responsive to the population‟s needs and aspirations. BKKBN has supported

some good governance initiatives – for example, supporting local NGOs in their watch-dog

functions – but they could show much more leadership in promoting good governance in the

FP program. To date BKKBN invests far more energy in protecting the legal status of FP in

government decrees and development plans than in ensuring a growing role for public

accountability.

4d Other recent developments in FP and population policy

There are a number of other recent developments in FP and population policy in Indonesia

which are important for understanding the current situation.

15

Hull and Mosley review

There have been a number of reviews of the current status of FP in Indonesia in recent years

(e.g. Hayes, Lewis and Vogel 2003; Hayes 2006). The most important is that undertaken by

Hull and Mosley in 2009, entitled Revitalization of Family Planning in Indonesia. Hull and

Mosley discuss many of the same issues discussed in this report. Their recommendations are

reproduced in Table 7, together with snippets from their accompanying justification and

clarification, and some additional brief comments of our own.

Table 7. Recommendations from Hull and Mosley Review

Recommendation Comment 1 Reformulate the vision, mission and

values [of the program]

“… Through this process a new identity will

be created for the BKKBN …”

2 Begin the process of building the core

analytical and technical competencies

related to family planning in the

decentralized and mixed public private

system of governance that has emerged

since 1998

“The central government needs to take the

lead in promoting core competencies at all

levels of government and in both the public

and private spheres. In particular a central

agency concerned with revitalizing FP will

need to harness the social and behavioural

sciences … The BKKBN has some nascent

skills in these areas, but lacks the breadth,

depth and focus to achieve the quantity and

quality of work required.”

3 Develop a senior leadership advisory

structure

“In order to gain the commitment of key

stakeholders and maintain a central agency

charged with revitalizing the family planning,

reproductive health, and population program

…”

4 Initiate leadership capacity building for

reproductive health and family planning

in the districts/municipalities

“This must be a collaborative effort with the

Home Ministry, the Ministry of Health and

the State Ministry of Women‟s

Empowerment. …”

5 Strengthen the role and functions of the

new offices/boards of family planning

and women and development that have

superseded the previous BKKBN offices

“In collaboration with the Ministry of Health

…”

Comment: BKKBN is trying to do this.

Turnover of staff at the district level makes

provision of TA to districts difficult.

According to BKKBN, many districts still see

FP as a matter of population control.

6 Promote initiatives to increase nationally

and locally the availability and

accessibility of long acting

contraceptives – IUD, implants and

sterilization – to all couples

“The current program of contraceptive

delivery gives too many provider incentives

for the use of injectables, and too little

support for vasectomy, implants and

tubectomy. …”

Comment: In fact the issue of incentives

needs to be addressed in each of the 12

recommendations, not only in this one.

7 Formulate program policies and develop

operational strategies in collaboration

with the Ministry of Health to meet the

critical service delivery needs including:

a. Reaching disadvantaged women

Comment: Everyone talks of collaboration

between BKKBN and MOH. In formal

presentations both parties say they “work

closely” with each other; in practice this

collaboration is clearly a persistent irritation

16

including women with an unmet

need for contraception with

information and services

b. Engaging the private sector with

training, technical assistance and

incentives to ensure that all

women can choose the

contraceptive method best for

their life stage

c. Assuring that women are not

forced to undergo unsafe

abortions, and that all women

terminating pregnancy are

provided with contraception

for both parties. Without addressing this issue

as a structural problem invoking

collaboration may prove little more than

“papering over” the issue. If this

collaboration had worked well it is unlikely

the FP program would be in the dire state it is

today.

More research still needed to help identify

who these women are and the factors driving

their behavior.

8 A central agency charged with

responsibility for family planning and

reproductive health should place a high

priority on monitoring public and private

program performance (from service

statistics and surveys) with interpretation

and rapid feedback to

districts/municipalities

9 Develop and promote national

communication strategies focusing on

the major unmet needs and unreached

groups

Comment: This is a major concern of

BKKBN, but new strategies not yet finalized.

10 The agency should also test and

introduce innovations, primarily through

grants to universities, private

organizations and NGOs as appropriate

“This activity needs to be closely coordinated

with the Ministry of Health.”

11 The agency should encourage

districts/municipalities to innovate and

take other actions to strengthen

programs, primarily through “block

grants”

Comment: There is now considerable

experience with the block grants mechanism

in Indonesia. The problems with

implementation typically relate to the central

government releasing funds late, and the use

of the grants being constrained by a

confusing and often onerous regulatory

environment established by the central

government (Hayes et al. 2007).

12 The agency should conduct advocacy,

nationally and internationally, based on

critically analysed data

“This will not only be for increased support

for all components of the family planning

program, but also for new policies to ensure

that unmarried women and women seeking to

terminate a pregnancy can get safe,

confidential services without stigma.” Source: Hull and Mosley (2009: 49-53).

This review was followed by another which suggested operational strategies for

implementing the Hull and Mosley recommendations (Lewis and Haripurnomo 2009). Eight

strategies were outlined:

Strategy to support the role of the private sector in RE/FP

Strategy for technical support for decentralization

17

National communications strategy

Capacity building strategy to address decentralization and priorities in RH/FP

Strategy to improve the quality of RH/FP

Support strategy for ensuring equity in access and use of RH/FP services

Strategy for preventing high risk pregnancies

Strategy for balancing the contraceptive method mix.

BKKBN has adopted some of these recommendations, although not necessarily in ways that

others would regard as engendering a “revitalization” of the FP program. For example

BKKBN has begun to address the issue of method mix, but the lynchpin of their strategy is to

provide all contraceptive methods free of charge: i.e. a strategy which secures a large

procurement budget for the agency without requiring any significant organizational reform. It

is not clear how this strategy adds value to “working closely” with the MOH (the phrase often

used in public statements) or adds value to implementing effective decentralization; and no

premium appears to have been placed on providing contraceptive methods in a cost-effective

way. The fact that BKKBN can command such a large procurement budget demonstrates the

agency still has a lot of political capital, but it is being spent mostly to maintain business as

usual, not to introduce innovative reform.

The Hull and Mosley recommendations are eminently sensible and well thought out. These

qualities are rarely sufficient in any democracy to ensure the government will adopt them. In

Indonesia government agencies are still largely neo-patrimonial bureaucracies; promotion in

the civil service is still not clearly determined by performance, although this is slowly

changing. Key political decisions are often determined by webs of patronage and the capacity

to capture and command resources. Under these circumstances it is hard for any agency to

adopt changes on the grounds that they will result in everyone doing a better job at serving

the needs and aspirations of the public. It is hard to introduce evidence-based reforms

designed to improve an agency‟s performance without further civil service reform

(Synnerstrom 2007).

5 Recommendations

Our recommendations are presented as discussion questions for the coming High-level

Family Planning Consultation Meeting in Bangkok, 8-10 December 2010.

Recommendation 1. Can Indonesia’s national FP program be given a central focus to

meet all remaining unmet need for services by 2015?

The FP program does not have a clear focus at present. Its core business should be reducing

unmet need but little progress has been made on this during the last 15 years. Unmet need is

primarily a health and reproductive rights issue and it needs to be addressed urgently for a

number of reasons. Unmet demand for FP services means that millions of women in

Indonesia today are at risk of unwanted pregnancy. This is a serious health and gender issue.

Focusing the FP program on reducing unmet need for FP services is the kind of challenge

which could revitalize the program. It is a goal which has major health benefits and which

18

promises to empower more women (and couples), together with all the flow-on benefits this

entails. It is also a goal which enjoys almost universal support, both in-country and

internationally, and which if accomplished will help the nation reach its MDGs as well as

achieve the ICPD target of universal access to FP by 2015.

Recommendation 2. Can primary responsibility for FP policy be transferred to the

Ministry of Health within the next few years?

BKKBN was established at a time when there was a recognized massive “population

problem” in the country which related to very high fertility levels and a high population

growth rate, and the international community supported population control programs at the

time. Neither condition is true today.

Thanks largely to the successful efforts of BKKBN the original “population problem” has

been brought under control. Family planning is now the prevailing norm in Indonesia,

although responsible practice is low for some groups and in some parts of the country. Less

than a quarter of those couples practicing FP rely on the government to provide them their

services. The country as a whole is close to replacement-level fertility. For most of the

population whether fertility continues to fall or whether it edges up again will depend more

on social and economic conditions than actions introduced by BKKBN. Fertility levels need

to be monitored carefully but so far there is no compelling evidence to suggest there will be

major baby boom if BKKBN no longer manages the FP program.13

In short, there is no

convincing argument for maintaining indefinitely a separate agency with primary

responsibility for family planning policy formulation outside the Ministry of Health.

Giving the MOH responsibility for FP policy will facilitate the integration of FP into the

broader cluster of reproductive and maternal health services in the way envisioned by ICPD.

Without “repositioning” the FP program in this way it is difficult to see how it can ever be

revitalized.

Recommendation 3. Can a new vision and mission be developed for BKKBN which

satisfies three requirements: (i) it is centered on an holistic vision of population policy

and its role in development; (ii) it is acceptable to other parts of the government if it is

assumed by BKKBN; and (iii) it is a vision and mission which is attractive to BKKBN

itself and which gives the organization an exciting future?

The new Population Law (Law 52/2009 on Family Planning and Population Development)

gives BKKBN explicit responsibility for population policy, and the name of BKKBN has

been changed accordingly (while still conveniently keeping the same acronym).14

BKKBN is

not happy with the way the new responsibility has been assigned to them because it is not

associated with sufficient status within the government structure for them to be able to fulfill

13

Reports in the press about the risk of a new population explosion following the release of preliminary results

from the 2010 Population Census are mostly ill-informed. 14

BKKBN used to stand for Badan Koordinasi Keluarga Berencana Nasional (National Family Planning

Coordination Board), it now stands for Badan Kependudukan dan Keluarga Berencana (National Family

Planning and Population Board).

19

this responsibility effectively. But there is the seed of a promising core mission here. If

BKKBN embraces it and advocates with the skill and persuasion it has traditionally displayed

for the status and resources it needs to do the job well, then this could be a new and exciting

beginning for an institution that is already a legend in population policy circles around the

world.

6 Conclusion

Indonesia has a mature FP program which appears to have lost its way now that it has

substantially realized its original objective. Neither BKKBN nor the MOH are happy with the

present status of FP in the country. Plenty of “band-aid” solutions have been suggested in

recent years, but if the FP program is to be revitalized and responsive to the evolving needs

and aspirations of the population this will require significant structural changes in the current

institutional arrangements.

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